Palliative percutaneous aortic balloon valvuloplasty before noncardiac operations and invasive diagnostic procedures

Percutaneous aortic balloon valvuloplasty (PABV) is useful in palliating symptoms of severe aortic stenosis in patients who are not candidates for aortic valve replacement. In 15 patients who had severe aortic stenosis and a contraindication to aortic valve replacement, PABV was performed before a noncardiac procedure, in an attempt to improve their hemodynamics and reduce the risks associated with the operation or preoperative diagnostic test. The mean aortic gradient was reduced from 58.1 +/- 6.0 mm Hg to 32.2 +/- 4.0 mm Hg (P less than 0.0002), and the aortic valve area was increased from 0.49 +/- 0.04 cm2 to 0.85 +/- 0.10 cm2 (P less than 0.0002). Complications associated with PABV included left ventricular perforation in three patients (which resulted in death in one of them), transient congestive heart failure in one, and development of femoral pseudoaneurysms in one. After PABV, nine patients underwent the planned surgical procedure under general anesthesia without complications. Five patients underwent surgical diagnostic procedures after PABV that resulted in a change in treatment strategy. Three of these patients required no further treatment, and two required resection of the colon for bleeding, which was preceded by aortic valve replacement. This study demonstrates that PABV may be useful in reducing the risks of noncardiac procedures in selected patients with severe aortic stenosis who are otherwise not candidates for aortic valve replacement.     

Outcome of noncardiac operations in patients with severe coronary artery disease successfully treated preoperatively with coronary angioplasty.

The risk of perioperative myocardial infarction and death was evaluated in 50 patients (mean age, 68 years) with severe coronary artery disease who underwent a noncardiac operation after revascularization had been achieved by successful percutaneous transluminal coronary angioplasty. Before angioplasty, all patients were thought to be at high risk for perioperative complications on the basis of assessment of clinical variables and findings on specialized diagnostic tests. Of the 50 patients, 31 had Canadian Heart Association class III or IV angina or unstable angina. All patients who underwent functional testing had positive results. At catheterization, 38 patients (76%) had multivessel disease. The 50 patients underwent 54 noncardiac operations at a median of 9 days after angioplasty. The overall frequency of perioperative myocardial infarction was 5.6%, and the mortality was 1.9%. Two nonfatal non-Q-wave infarctions and one fatal Q-wave infarction occurred. In patients who have undergone successful angioplasty for severe coronary artery disease, the risk of major cardiac complications associated with a noncardiac surgical procedure is low.     

Timing of operation in asymptomatic severe aortic stenosis

Calcific aortic stenosis is now the main cause of aortic stenosis in the majority of patients, due to declining incidence of rheumatic fever. Risk factors such as hyperlipidemia play an important role in the progression of aortic stenosis. According to the most recent American College of Cardiology/American Heart Association guidelines, peak velocity greater than 4 m/sec, a mean gradient of more than 40 mmHg and a valve area of less than 1.0 cm(2) is considered hemodynamically severe aortic stenosis. Aortic valve surgery promptly should be done in symptomatic patients due to dismal prognosis without operation. Features such as high aortic valve calcium and positive exercise test identify asymptomatic patients who would benefit from early aortic valve surgery. Due to improvement in surgical techniques and better prosthesis, aortic valve surgery can now be offered at low risk to a selected group of asymptomatic patients with severe aortic stenosis. Currently percutaneous aortic valves are used in very high-risk patients with severe symptomatic aortic stenosis. Their role may expand in the future, depending on the improvements in design and operator experience. Whether advances in molecular cardiology lead to novel therapies in preventing calcific aortic stenosis in the future remains to be seen.     

Impact of intraoperative transesophageal echocardiography among patients undergoing aortic valve replacement for aortic stenosis.

In this study, we sought to define the impact of intraoperative transesophageal echocardiography (IOTEE) among patients undergoing aortic valve replacement for severe aortic stenosis. We reviewed the clinical data and preoperative, intraoperative, and postoperative echocardiograms of all adults who underwent aortic valve replacement for aortic stenosis and had IOTEE between January 1993 and December 1996. There were 383 patients (223 men, 160 women; mean age, 69 years). Fifty-four (14%) of the 383 patients had mitral valve surgery at the time of aortic valve replacement. In 6 patients, mitral valve surgery was not planned but was added because of findings on IOTEE. In 25 patients, mitral valve surgery was canceled on the basis of the IOTEE. Additional information was found by IOTEE in 25 patients before and after bypass, altering the surgical plan in 18 of these 25 patients. Overall, IOTEE altered the planned operation in 49 (13%) of the 383 patients. These data support the routine use of IOTEE among patients undergoing aortic valve replacement for aortic stenosis.     

血液透析患者的主动脉瓣钙化

目的探讨血液透析患者主动脉瓣钙化及钙化所致的瓣膜狭窄的发生发展及其对心脏功能的影响。方法通过心脏超声检查观察上海市浦东新区人民医院110例终末期肾病(ESRD)血液透析患者主动脉瓣膜钙化程度、瓣口面积及相关的生化指标,同时选择100例无肾脏疾病、无风湿性疾病的患者作对照组。结果ESRD患者组发现主动脉瓣钙化48例,占43.64%,发生瓣膜钙化的平均年龄(56.4±14.6)岁;对照组发现主动脉瓣钙化22例,占22%,平均年龄(68.5±10.3)岁。主动脉瓣钙化所致主动脉瓣狭窄ESRD患者组9例、对照组2例。ESRD组钙化者(AVC)的平均透析龄为(33.37±27.6)月,ESRD组无钙化者的平均透析龄为(20.82±18.6)月,(P<0.05)。结论慢性肾衰竭血液透析患者主动脉瓣钙化发生率高、进展至主动脉瓣狭窄快,主动脉瓣钙化发生、发展与继发性甲状旁腺功能亢进、高磷血症和透析年限有密切相关。     

Timing of operation in asymptomatic severe aortic stenosis

Calcific aortic stenosis is now the main cause of aortic stenosis in the majority of patients, due to declining incidence of rheumatic fever. Risk factors such as hyperlipidemia play an important role in the progression of aortic stenosis. According to the most recent American College of Cardiology/American Heart Association guidelines, peak velocity greater than 4 m/sec, a mean gradient of more than 40 mmHg and a valve area of less than 1.0 cm² is considered hemodynamically severe aortic stenosis. Aortic valve surgery promptly should be done in symptomatic patients due to dismal prognosis without operation. Features such as high aortic valve calcium and positive exercise test identify asymptomatic patients who would benefit from early aortic valve surgery. Due to improvement in surgical techniques and better prosthesis, aortic valve surgery can now be offered at low risk to a selected group of asymptomatic patients with severe aortic stenosis. Currently percutaneous aortic valves are used in very high-risk patients with severe symptomatic aortic stenosis. Their role may expand in the future, depending on the improvements in design and operator experience. Whether advances in molecular cardiology lead to novel therapies in preventing calcific aortic stenosis in the future remains to be seen.     

Fate of bicuspid aortic valves in patients undergoing aortic root repair or replacement for aortic root enlargement

OBJECTIVE: To better understand the outcome of the bicuspid aortic valve (BAV) after valve-sparing root replacement, we evaluated BAV function after its preservation at the time of the ascending aorta (AA) repair. PATIENTS AND METHODS: From January 1, 1994, through March 31, 2002, BAVs were preserved during repair of AA aneurysms in 21 patients (mean +/- SD age, 45+/-12 years; 13 males). We reviewed the clinical and surgical records of these patients for baseline characteristics, operative procedures, and data at latest follow-up. RESULTS: The primary indication for operation was AA enlargement (median diameter, 55 mm; range, 43-65 mm) in 18 patients and severe aortic regurgitation (AR) in 3 patients. Preoperatively, the BAV exhibited mild or moderate stenosis in 5 patients (mean gradient, 25 mm Hg; range, 19-34 mm Hg), moderate AR in 2, and severe AR in 3. Aortic valve repair was performed in 11 patients. Seventeen patients had excision and graft replacement of the enlarged AA, and 4 patients had primary AA repair. There were no perioperative deaths. Moderate or severe AR was relieved in all patients early postoperatively and during follow-up (median, 2.5 years; maximum, 7.6 years). One patient required aortic valve replacement at 4.8 years for AR. An additional patient had recurrent, severe AR but was asymptomatic and has not undergone reoperation. CONCLUSION: Repair of diseased BAVs or preservation of functionally normal BAVs during surgery for AA aneurysms has a low perioperative risk, and early results are encouraging. Additional observation is necessary to determine whether this strategy has real advantages over early aortic valve replacement.     

Local versus general anesthesia for transfemoral aortic valve implantation

Background

Transcatheter aortic valve implantation (TAVI) represents a novel option for elderly with severe aortic valve stenosis who are denied surgical aortic valve replacement due to high perioperative risk. While transfemoral TAVI generally is being performed in general anesthesia (GA), TAVI under local anesthesia plus mild sedation (LAPS) might be an effective and safe alternative.

Methods

In a single-centre analysis, we assessed clinical data, preoperative risk scores (STS-Score), echocardiography, periprocedural data and labor costs in 74 patients undergoing transfemoral TAVI under GA (n?=?33) and LAPS (n?=?41).

Results

Patients who underwent TAVI in LAPS presented significantly more often with pulmonary hypertension and impaired renal function, and tended to have a higher STS score and more severe symptoms (higher NYHA class) versus the GA group. There were no significant differences in procedure-related 30-day mortality or complications between groups. The peak systolic and mean central aortic pressure were significantly higher in the LAPS group, while at the same time these patients required significantly less often periprocedural adrenergic support. Intervention time was shorter in the LAPS group due to avoidance of surgical cut-down of the access site. Moreover, total procedure time was significantly shorter and labor costs were lower in the LAPS group. Patients who underwent TAVI in LAPS could be mobilized significantly earlier.

Conclusion

Our study indicates that TAVI under LAPS is as effective and safe as TAVI under GA. Furthermore, total procedure time, intervention time and labor costs could be reduced by LAPS. Mobilization of patients could be achieved earlier. We therefore consider LAPS to be favorable in patients undergoing transfemoral TAVI.     

非心脏手术围手术期心脏事件预测的超声心动图研究现状

对非心脏手术病人进行准确的术前心脏事件危险性评估可以帮助临床采取预防性保护措施并制定合理的治疗方案,降低围手术期心脏事件的发生.采用何种合适的术前检测方法和恰当的术前风险评估一直是临床关注的研究热点.超声心动图,特别是负荷超声心动图通过对非心脏病人术前心脏各指标的检测,可以对围手术期心脏事件的危险性进行分级,被认为是有潜在价值的评估非心脏手术病人心脏事件发生的有效方法.     

多巴酚丁胺负荷超声心动图对低压力阶差低心排血量主动脉瓣狭窄的研究

目的 评价负荷超声心动图技术在诊断低跨瓣压力阶差-低心排量主动脉瓣狭窄中的作用。方法 对经临床拟诊和经胸超声心动图（TTE）确定为低跨瓣压力阶差-低心排量主动脉瓣狭窄的12例患者进行回顾性分析,并均行多巴酚丁胺超声心动图负荷试验予以确定病变性质。结果 8例患者呈重度主动脉瓣狭窄伴左心功能不全,左室有收缩储备,外科手术换瓣均成功（除1例死亡外）;其余4例予内科药物治疗。结论 多巴酚丁胺超声心动图负荷试验对鉴别低跨瓣压差低心排的主动脉瓣狭窄是有效、安全的方法。     

巨大左心室瓣膜置换术的外科治疗经验

目的总结合并巨大左心室的心脏瓣膜置换术的外科治疗经验。方法1998年7月至2007年4月51例合并巨大左心室的心脏瓣膜病人实施换瓣术。其中主动脉瓣置换术34例，双瓣置换术17例；同时行左房折叠术12例，三尖瓣成形术17例。结果术后早期死亡8例（占15．7％），晚期死亡6例（占11.8％）。影响瓣膜置换术早期疗效及导致死亡的主要因素是术前严重左室扩大，舒张末直径（LVEDD）〉8．5cm；严重左室收缩功能下降，射血分数（EF）〈0．40；术后恶性心律失常和严重低心排以及多脏器功能衰竭；术后室颤和术前严重左室扩大伴收缩功能下降也是导致晚期死亡的主要原因。结论对心脏左室功能的正确评估、手术适应证和时机的选择、围术期的正确处理是治疗关键。     

Successful administration of levosimendan in a patient with low-gradient low-output aortic stenosis

Aortic valve replacement in patients suffering from low-gradient aortic stenosis and congestive heart failure is associated with high operative mortality, and the perioperative use of inotropes is common. Levosimendan is a calcium sensitizer with positive inotropic and vasodilatory effects and has been developed for treatment of decompensated heart failure. Although its use in patients with low-gradient aortic stenosis is not established, we hypothesized that it might have beneficial effects on outcome after aortic valve replacement. We report on a high-risk operation in a 73-year-old man with low-gradient aortic stenosis, congestive heart failure and coronary artery disease. Levosimendan was administered perioperatively (0.1 mg/kg/min 16 hours prior to the operation without a loading dose) and allowed rapid recovery of the patient, who required only brief treatment in the intensive care unit. No levosimendan-specific adverse events were observed, in particular no hypotension. The excellent postoperative result was maintained after the patient was discharged from hospital.     

Severe aortic and mitral calcification in identical twin boys.

Identical twin boys presented with exercise-induced syncope. Echocardiographic examination revealed severe calcification at aortic valves, mitral anterior leaflets, and mitral annuli in both patients. In addition, basal interventricular septum was also involved in 1 patient. Doppler evaluation demonstrated severe aortic stenosis with a peak gradient of 112 and 118 mm Hg in both patients. Moderate mitral stenosis was also detected in one of them. Patients underwent operation for valve replacement.     

The safety of electroconvulsive therapy in patients with severe aortic stenosis

Little is known about the safety of electroconvulsive therapy (ECT) in patients with severe aortic stenosis and depression and other psychiatric syndromes. We conducted a retrospective review of the medical records of 10 patients with severe aortic stenosis who underwent ECT at Mayo Clinic, Rochester, MN, between January 1, 1995, and June 30, 2006. Of the 10 patients, 6 (60%) were women. The median age was 79.5 years (range, 65-93 years). All patients had an aortic valve area of 1.0 cm2 or less (median, 0.9 cm2). The median aortic transvalvular pressure gradient was 43.5 mm Hg (range, 32-58 mm Hg). The 10 patients underwent a total of 144 ECT sessions (range, 1-37 sessions per patient). Despite this large number of sessions, only 2 patients experienced single episodes of blood pressure perceived to be low 1 minute after an electroshock; these episodes were successfully treated. Hypertensive systolic blood pressure (Greater than 180 mm Hg) and tachycardia (greater than 100 beats/min) in response to ECT prompted treatment in 7 patients during 70 ECT sessions (49%). None of the patients died within 24 hours after dismissal from the postanesthesia care unit (95% confidence interval for death rate per person, 0%-26%). Hence, ECT was safe in 10 patients with severe aortic stenosis treated at our institution. Our findings may be informative to clinicians who manage the care of patients with severe aortic stenosis who are undergoing ECT.     

Assessing the Risk of Aortic Valve Replacement for Severe Aortic Stenosis in the Transcatheter Valve Era

Surgical aortic valve replacement had been the only definitive treatment of severe aortic stenosis before the availability of transcatheter valve technology. Historically, many patients with severe aortic stenosis had not been offered surgery, largely related to professional and patient perception regarding the risks of operation relative to anticipated benefits. Such patients have been labeled as “high risk” or “inoperable” with respect to their suitability for surgery. The availability of transcatheter aortic valve replacement affords a new treatment option for patients previously not felt to be optimal candidates for surgical valve replacement and allows for the opportunity to reexamine the methods for assessing operative risk in the context of more than 1 available treatment. Standardized risk assessment can be challenging because of both the imprecision of current risk scoring methods and the variability in ascertaining risk related to operator experience as well as local factors and practice patterns at treating facilities. Operative risk in actuality is not an absolute but represents a spectrum from very low to extreme, and the conventional labels of high risk and inoperable are incomplete with respect to their utility in clinical decision making. Moving forward, the emphasis should be on developing an individual assessment that takes into account procedure risk as well as long-term outcomes evaluated in a multidisciplinary fashion, and incorporating patient preferences and goals in a model of shared decision making.     

Balloon valvuloplasty of aortic valve stenosis in childhood: early and medium term results

BACKGROUND: Isolated aortic valve stenosis in childhood is treated by balloon valvuloplasty. The role of independent risk factors for the outcome remains unclear. MATERIAL AND METHODS: We analysed the early and medium term outcome of balloon valvuloplasty in isolated aortic valve stenosis in 44 pediatric patients with isolated, severe aortic valve stenosis at an age younger than 18 years, who received a primary balloon valvuloplasty during the last 5 years in our institution. We evaluated the type of aortic valve morphology, age, clinical status, and myocardial function at the time of the intervention as independent risk factor. RESULTS: A significant early relief of the pressure gradient across the aortic valve (P < 0.001) after balloon valvuloplasty was found. This was independent of the aortic valve morphology. Two neonates with a highly stenotic tricuspid aortic valve and severely compromised haemodynamics died within the first 30 days after the intervention. During medium term follow up (mean 22.5 months) we observed a functional deterioration for the stenosis as well as for the insufficiency of the aortic valve. "Symptoms before intervention" is an independent risk factors (P < 0.001) for valvuloplasty failure. Patients at an "age at intervention 相似文献   

Measurement of the ascending aorta diameter in patients with severe bicuspid and tricuspid aortic valve stenosis using dual-source computed tomography coronary angiography

We aimed to evaluate the diagnostic performance of dual-source computed tomography coronary angiography (DSCT-CA) in the measurement of the ascending aorta (AA) diameter and compare the AA diameter in patients with severe bicuspid aortic valve (BAV) and tricuspid aortic valve (TAV) stenosis. Eighty-eight consecutive patients (50 men, mean age 60.3 ± 13 year) with severe aortic stenosis (AS) underwent DSCT-CA before aortic valve surgery. Seventy-four of the 88 patients underwent cardiovascular magnetic resonance (CMR). The internal diameter of AA was measured from early-systole with DSCT-CA and CMR by 2 radiologists independently at 4 levels (aortic annulus, sinuses of Valsalva, sinotubular junction, and tubular portion at the right pulmonary artery). The patients were divided in to 2 groups (BAV [n = 53]; TAV [n = 35]) according to operative findings. Patients with BAV were significantly younger than those with TAV (P = 0.0035). Inter-observer agreement of AA diameters at 4 levels with DSCT-CA and CMR was excellent (intraclass correlation coefficient = 0.89-0.97). Also, the DSCT-CA and CMR measurements of the AA diameter strongly correlated (r = 0.871-0.976). Mean diameter of the AA by DSCT-CA was significantly larger in patients with BAV (34.4 ± 8.2 mm) as compared to those with TAV (30.6 ± 5.5 mm). The diameters at the sinuses of Valsalva, sinotubular junction, and tubular portion were significantly larger in BAV than in TAV. Twenty-two of 53 (41.5%) patients with BAV and 2 of 35 (5.7%) patients with TAV had AA dilatation > 45 mm. DSCT-CA allows accurate assessment of the AA diameters in patients with severe AS. Patients with severe BAV stenosis had larger AA diameters and higher prevalence of AA dilatation > 45 mm as compared to those with severe TAV stenosis.     

Transcatheter Edwards Sapien XT valve in valve implantation in degenerated aortic bioprostheses via transfemoral access

Objectives

Surgical treatment of degenerated aortic bioprostheses is associated with an increased risk of morbidity and mortality, especially in elderly patients with significant co-morbidities. Therefore, transcatheter aortic valve implantation (TAVI) performed as valve in valve technique appears as an attractive alternative treatment option. We report of a case series of seven patients with dysfunctional bioprosthetic aortic heart valves who have been treated with TAVI via transfemoral access.

Methods and results

Valve in valve implantation using the Edwards Sapien XT bioprostheses (Edwards Lifesciences LLC, Irvine, CA, USA) was performed in eight patients (3 men, 5 women, mean age 85.3?±?6.1?years) with a high operative risk (logistic euroSCORE 27.2?±?7.3). Six patients underwent TAVI because of high grade stenosis of the aortic bioprostheses, whereas two patients presented with high grade regurgitation. All patients suffered at least from NYHA class III dyspnea during admission. TAVI was successfully performed via transfemoral access under local anesthesia with mild analgesic medication in all cases. Mild aortic regurgitation occurred in three patients while no permanent pacemaker implantation was required. Major cardiac events or cerebrovascular events did not occur. One aneurysm spurium, with the need of one blood transfusion, occurred. All patients improved at least one NYHA class within 30?days.

Conclusion

TAVI for degenerated aortic bioprostheses, using the Edwards Sapien XT valve via transfemoral access is a feasible option for patients at high surgical risk.     

Non-invasive variant of Gorlin formula can be used to identify severe aortic stenosis

Summary. In recent years the continuity equation has been established as a valuable non-invasive method for calculating aortic valve area. The continuity equation cannot be used if there is calcification or sub-valvular stenosis in the left ventricle-outflow tract, because the area of the outflow trace is not circular in those cases. The authors have tested the value of a non-invasive variant of the Gorlin formula, as an alternative method of identifying severe aortic stenosis. They examined 32 consecutive patients with aortic stenosis with both methods. Seventeen patients had severe stenosis (valve area^0–7 cm²), calculated by the continuity equation. The other 15 patients had moderate stenosis (valve area 0–7–1–0 cm²). Using the non-invasive variant of the Gorlin formula, the authors were able to identify 16 of the 17 cases with severe stenosis, thus showing that the method is useful for identifying severe aortic stenosis. (P<0–001 by x²-test).     

Clinical outcome and functional characteristics of patients with asymptomatic low-flow low-gradient severe aortic stenosis with preserved ejection fraction are closer to high-gradient severe than to moderate aortic stenosis

Asymptomatic “paradoxic” severe low-flow low-gradient aortic stenosis with preserved ejection fraction (PAS) constitutes a challenging condition where the optimal management and follow-up remain elusive. We evaluated the clinical outcome in patients with PAS as compared to asymptomatic patients with moderate (MAS) or classical severe aortic stenosis (CAS). Consecutive asymptomatic moderate or severe aortic stenosis patients without concomitant other heart or lung disease (n?=?121) were invited. Participants (n?=?74) were assigned to three subgroups with regard to degree of aortic stenosis: MAS (n?=?25), CAS (n?=?22) and PAS (n?=?27). Echocardiographic parameters at baseline and clinical outcome data after >?3 years of follow-up time were obtained. Patients with PAS had the smallest stroke volumes and the highest relative wall thickness (p?<?0.05). Left ventricular mass index was highest in subjects with CAS, followed closely by PAS and eventually MAS subjects. Whereas ejection fraction was similar amongst the subgroups, a stepwise decrease in global longitudinal left ventricular strain with increasing degree of aortic stenosis was observed, with CAS patients displaying the lowest mean global longitudinal strain, followed by PAS and MAS. A trend towards increasing mortality rate by increasing degree of stenosis was observed. Patients with CAS underwent aortic valve replacement surgery more frequently than both PAS and MAS (p?<?0.001). These data suggest that echocardiographic parameters and clinical outcome in patients with PAS bear closer resemblance to CAS than to MAS, but management of PAS is more conservative than in CAS.